HomeMy Public PortalAbout8810 HERMOSA DR_Mechanical__ FAtO'OIERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
hereby 6ffkm that I have a certificate of consent to self
ora c,'or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) CE-B18(REV. 10/81)
Policy No..Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING? p
tion deportment. '1y /, (PRINT OR TYPE ONLY) ADDRESS 8� &bd
Dot Applicant , -11 V L wtfb/ LOCALITYNO. TYPE OF APPLIANCE OR EQUIPMENT FEE Ae`/
CERTIFICATECOMPENSATION INSURANCEPTION FROM CROSS
NEARECROSSSST. 0 S JVJ-Pem d-
70 y e-
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT No. PROCESSED By
the permit is for one hundred dollars ($100)or less.) f UX a ;/
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE XS TOR'S SIGNATD E
Date Applicant COMPRESSOR, BTU k ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_ R ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code, and my license is in full force and effect. - 1
O
License Number Lic. Class , V
fY
Contractor Date WO
❑ I am exempt under Sec. W
Plan check fee d
6.8P.C. for this reason NPERMIT ISSUING FEES Z
Date:
Signature T TOTAL FEE 9jG �i
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
I hereby affirm that I am exempt from the Contractor's License �/ /' /��1/ ;@1 Q1 1 A
Law for the following reason (Section 7031.5, Business and NAME Sn l�uZ_/ (fM W/dV ,
Professions Code
x ) ADDRESS get Q I, I e s 4 e e 8
'f\ I, as owner of The property, or my employees with JI Q If'T6 �✓Cl.
wages as their sole compensation,will do the work and ;5v-/C/f 'I e - 3Q50
the structure is not intended or offered for sale(Section CITY '�`.Q/�,1 '"'e TEL. NO.
7044, Business and Professions Code). � is e o 3 G5 05
OWNER
❑ 1, as owner of the property, am exclusively contracting S OIC7 u C.- N/d/Ilw!
with licensed contractors to construct the project (Sec- MAIL OOPI 8 a
tion 7044, Business and Professions Code). ADDRESS 6"g p VS r{ I Q2 7:
CONSTRUCTION LENDING AGENCY CITY TEL. NO. o /�
I hereby affirm that there is o construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY NO.
Lender's Address
STATE C
I certify that I have read this application and state That the� LICENSE NO. CLASS
above information is correct. I agree to comply with all County - -
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-me boned property for in
Toon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig rure o4 Applicant or Age d
Dote